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SAN .RUIN COUNTY ENVIRONMENTAL HEALTH [ORTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" <br /> GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USEONL OWNERID# CARE If UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEcx IFOWNERIs COaRENnroNFAEWIrH EHD <br /> PROPERTYOWNERNAME George Betker (201 848-3272 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME Geo Properties, Inc . E-1IAILADDRESS <br /> OWNERHOMEADDRESS 2306 Jackie Court <br /> CITY Oakdale STATE CA ZIP 95361 <br /> OWNER MAILING ADDRESS Same as above <br /> MAILINNGG ADDRESS CITY STATE ZIP <br /> Ey CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_ WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY 100 INV/ ACCOUNT IO PR#I RO# ASSIGNED EMPLOYEE LEAD :END. DT$O_EP <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEB ❑ NO [� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YEs No ❑ <br /> BUSINESSIFACILITYISITEIPROJECTNAME Former JM Equipment <br /> SITE ADDRESS/PROJECT LOCATION 1245 W. Charter Way SUITE# BUSINESS PHONE none <br /> CITY Stockton '—CA ZIP 95206 <br /> r"! <br /> NDISTRICT LOCATION CODE KEY1 KLY2 <br /> DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> 2306 Jackie Court <br /> Y Oakdale STATE CA ZIP 95361 <br /> APN# CCWRENr: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) <br /> MAILING ADDRESS PHONE <br /> CITY STATE ZIP <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERLTX FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Parry and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. 1 also certify that all <br /> information provided on this application is true and corred;and that all regulated activities will be performed in accordance with all applicable SAN JOAQmN COUNTY ORDINANCE CODES and/or <br /> STANDARDS mal STATE and/or FEDERAL Laws and RECL I.nnoNS. As the undersigned Owner,Opemmr,Aur/mrized Agent,or Responsible Parry for the project located above ander facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUEN Co"Tre ENVIRONMENTAL HEALTH DEPARTMENT M soon as it is available <br /> and at the same time It is provided to me or my representadw. <br /> APPLICANT NAME(PLEASE PRINT) George Betker SIGNATURE �-'Ti �fY� �(� <br /> TITLE 1 n Tax ID# "% / — 3 EI S ) -L ' <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORKPuNPE <br /> FEE:; <br />